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The Perspective

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Precious Obana

on 25 March 2014

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Transcript of The Perspective

Substance Abuse
The Treatment Plan
When planning their treatment plan, hygienists must keep in mind:
The client’s safety, and the effectives of the planned treatment
Any Drug Interactions
Adverse effects may occur with anesthetic (especially epinephrine), Nitrous Oxide, Prescribed pain meds, anti-inflammatories
Pain management and drug tolerance
Appointment duration: short appointments 
Aesthetic work should be completed last to serves as motivation for client’s to continue attending all appointments.
(Darby and Walsh, 2010)
Mental Illness
Treating Clients
with Special Needs
What is a Physical Disability?
What is Mental Illness
Disease of the mind
Cause of mental illness can be associated with negative experience or behavioral, psychological, and biologic abnormality in the individual
Requires psychiatric intervention
Broad classification for many mental health problems
Common in North American population, 1 in 5 Canadians (6 million people) Suffer
Most often its unrecognized and untreated, and is misunderstood
Impacts people of all ages, education, income levels, religions, cultures and in many types of jobs

Juliana Barragan
Gabriella Arevalo

Tinika Edwards James
Jessica Loja
Priyanka Patel
Precious Obana

Physical
Disabilities
The
Perspective

Any limitations to perform any sort of physical functions in our everyday life.
According to Wilkins, “many conditions related to the neuromuscular system, joints, or connective tissue have as a symptom, or leave as a chronic after-effect, loss of function in the form of a physical impairment” (Wilkins, 2013, p. 886).

Caused by disease, trauma or any sort of abnormality

Conditions that can cause Physical Disability
Cerebrovascular accident (stroke)
Bell’s Palsy
Multiple Sclerosis
Amyotrophic Later Sclerosis
Parkinson’s Disease
Myasthenia Gravis
Post-polio Syndrome
Cerebral Palsy
Muscular Dystrophies
Myelomeningocele
Arthritis
Scleroderma (progressive systemic sclerosis)

Assistive Devices
Wheelchair
Crutches
Walker
Cane
Leg Braces
Prosthetic Limbs
Three Classifications of Disability
Developmental disability
Acquired disability
Age associated disability
PHYSICAL DISABILITY & ORAL HEALTH
Four Functional Levels
Level I: perform almost all normal functions
Wheelchair Transfer
Clear the area
Explain the procedure to the client
Bring the wheelchair close to the dental chair
Prepare dental chair
Prepare transfer devices if required (sliding board or ask for another operator’s help)
Approach the client
Transfer

What needs to be done?
Implement proper daily oral self care plan
Regular dental exam
Prevention plan
Continuing care
Fluoride
Sealants
Client education
OSC
Nutritional counselling
Tobacco cessation

MODIFICATIONS TO DENTAL HYGIENE PROCESS OF CARE
Space
Time
Respect
Consent
Client position & Stabilization
Transfer

5 factors prior to introducing any prevention aids
1. Determine client’s skill level.
2. Determine the affects of physical disability on client’s daily oral self care.
3. Evaluate the oral health of the caregiver and his/her opinion about oral self care.
4. Determine aids that will best help the client depending on their ability.
5. Determine the easiest possible aid to best fit client’s needs to function independently.
PREVENTION AIDS
Level II: perform some functions with extra assistance
Level III: Perform function with the help of family member/caregiver
Level IV: Not able to function at all
Customized OSC aids
Extended handle toothbrush or floss picks

Compact head toothbrush

Wide bulky handle toothbrush
Universal cuff


Power toothbrush

What is Down Syndrome?
Also known as Trisomy 21 syndrome
Is a mental or intellectual disorder that is associated with an abnormality of chromosome 21 in all or some body cells (Darby, 2012)
the most common chromosomal abnormality
about 1 in 800 live births are affected, but this also varies with maternal age

Down Syndrome
Viewers Corner
Frequent Psychiatric Disorders in the dental office:
Schizophrenia
Mood disorders
Anxiety disorders

Schizophrenia
Schizophrenia is a complex chronic psychiatric disorder affecting an individuals thoughts, emotions, behaviour, overall health and social relationships
Onset is around ages 15-24 for males and 25-35 for women
The word Schizophrenia comes from the Greek origin, schizo meaning “split’ and phrenia “mind”
Misconception that schizophrenia is a split personality disorder (a less common condition)
Biochemical imbalance of the mind having lost touch with reality in the severe psychosis stage

Currently there are no blood test, radiographs, CT scans or MRIs that can diagnose Schizophrenia
Combination of genetics and biochemical factors that are responsible for causing a hyperactivity of dopamine at receptor sites in the brain
Triggers that can cause someone to be more susceptible to the illness, for examples: substance abuse, stressful psychosocial events, medical illness, and chronic stress of poverty
Signs & Symptoms
Schizophrenia presents in phases and tends to reoccur in a cyclical pattern which can vary from mild to severe
These phases are Prodromal, Active, Residual and Maintenance or Recovery
Auditory hallucinations are a very strong symptom
There is a dopamine disturbances, the brain has trouble directing and assimilating each message
There is a misdirection of signals by abnormal thought, emotion and response processes for the individual
Causes an individual to think they have no control over their thoughts or someone else is controlling what they think

Medications
Schizophrenia has no cure, yet can be treated with medications and psychotherapy to alleviate and reduce delusions, hallucinations and other symptoms
Help an individual stabilize and be able to function again in daily life
The medication prescribed for schizophrenia are Conventional Anitpsychotics (first generation) and Atypical Antipsychotics (second generation)
Conventional antipsychotic medications work for “positive” symptoms and less against the “negative” ones

Some examples of these medications:
Phenothiazines (Chlorpromazine [Thorazine])
Butyrophenones (haloperidol [Haldol])
Thioxanthenes (thiothixene [Navane])

Examples of Atypical drugs which have less motor side effects and work against the “negative” Symptoms:
Dibenzodiazepines (clozapine [Clozaril])
Benzisoxazoles (risperidone [Risperdal])
Olanzapine, quetiapine, ziprasidone, and others

Dental Hygiene Care
Dental Hygiene treatment is performed on a client who’s symptoms are reasonably controlled
Medical History: review for medications. understand side effects that could be present
Inquire on any information provided from the mental health physician relative to medications, substance abuse and medicolegal competence for informed consent
Make the appointment simple and stress-free by keeping the same routine each time and explaining in easy to understand terms
Caregiver, provide information and instruction to them as well
A mouth prop is ideal to help stabilize the jaw
Telephone numbers of the client’s physician, caregiver, emergency contact

Xerostomia: Saliva substitutes e.g. Biotene or saliva stimulants such as sugarless gum and candies containing xylitol
Avoid: alcohol, caffeine and carbonated beverages, this helps to decrease severity and decrease the erosive effects that the beverages will have on the already compromised dentition
On the other hand certain medications and do the opposite by stimulating an increased salivary flow, where the client is constantly drooling
Dietary counseling by suggesting to avoid easily accessible carbohydrates, sticky and slowly dissolving foods and chewy candies
Antibacterial mouth rinse such as Listerine as a part of their everyday routine to reduce oral bacterial counts and in some severe cases Chlorhexidine may be prescribed

Fluoride varnish: to prevent caries and reduce sensitivity
Tooth paste: Prevident from Colgate which contains a high dose of stannous fluoride
Hygiene appointments: including scaling, prophylaxis, oral hygiene instructions and a 3 month continuing care interval
History of drug and alcohol abuse: Note there may be damage if not irreversible damage to the liver. Client is more susceptible to hemorrhage, delayed wound healing, increased risk of infection, and can alter in drug metabolism

Only 10% of patients (clients) who abuse substances are identified by their health care professionals.
Their health and safety are at risk if their treatment plan does not take into consideration their drug abuse.
As dental hygienists we must not only ensure to take a thorough health history, but we must also be diligent in observing our client’s behaviors, and extra/intra oral findings.
As Darby and Walsh recognize, most clients with drug abuse will not reveal this information to their health care providers.
(Darby and Walsh, 2010)
Substance Abuse
Substance Abuse
Drug abuse is defined as “ The self administration of a drug in a manner that differs from its accepted medical use” (Darby and Walsh, 2010). There are drugs that offer no medical use, and so are illegal, there are individuals who abuse these sorts of drugs as well.
Alcohol, and nicotine are drugs that are legal and do not have a medical use. However they are used to alter the state of mind/body of individuals and are consequently classified as drugs
A drug addiction occurs when: its use is uncontrollable and disregards its harmful and debilitating affects .
Keeping in mind that substance abuse is independent of socio-economic status, will help defer any bias and instead will help foster an open mind.

Commonly Abused Drugs
-Nicotine
-Alcohol
-Opiods/morphine derivatives
-Stimulants
-Hallucinogens (ie: marijuana)
-Anabolic steroids
-Inhalants (ie: hairspray, and rubber cement)
-Depressants
-Sedative anesthetics

(Darby and Walsh, 2010)
During the extra oral examination the following may be present in client’s who abuse substances (Darby and Walsh,2010)
During the intra- oral examination the following may be present:
In the Journal of Substance Abuse Treatment a study named: “Dental care and oral disease in alcohol-dependent persons” outlined some important findings.
Amount of plaque found on their teeth remained relatively the same throughout the day.
Alcohol plays a role in biofilm accumulation.( Brushing, was monitored by research personnel.)
Additionally presence of periodontitis in alcoholics was inversely related to the number of dental visits and not to their alcohol use.
Alcoholics also reported to be unhappy with their oral health.(Janal et al.,2008)This information brings awareness to the essential role dental professionals need to play in provisioning a healthy lifestyle for substance abusers.

Managing clients who appear under the influence
Health and safety first
Reschedule appointments
Since:
There are drug interactions that could occur
Consent to treatment may be misunderstood by the client
Behavioral issues may arise
The client’s physician may need to be consulted
PAC may be necessary

(Darby and Walsh, 2010)
Medical Consult
It is imperative the dental hygienist sends a medical consult to the client’s physician, if a clients health is debilitated
BP Guidelines (CDHO)
Drugs may exacerbate a client’s BP, and put them at risk of having a heart attack/stroke
IV drug users need to be identified as a medical consult needs to be sent out.
Prophylactic Antibiotic Coverage (PAC) may be indicated for IV drug users, since they are at a higher risk for: valvular defects, heart defects, endocarditis, hep b,c,and d, and HIV/AIDS. (Darby,and Walsh, 2010)
Client Education
Hygienists may want to open the conversation with the following questions:

(1) Have you ever felt the need to cut down on your drinking or drug use?
(2) Have you ever felt bad or guilty about your drinking or drug use?
(3) Have you ever used or had a drink first thing in the morning, as an eye opener to steady your nerves or to feel normal?

If the client answers yes to 2 or more of the questions, the hygienist should actively participate in motivating the client to look for help

The Stages of Change Model- Will help determine client’s thought process

Client’s oral health status should be reviewed, and any observed oral drug effects should be addressed.
Easy to follow at home care instructions should be given to these clients.
At subsequent appointments, interdental aids should be introducedTherapeutic fluoride rinse should be recommended
These clients would also benefit from an antimicrobrial rinse
Xerostomia should be addressed with an appropriate toothpaste
Increasing water intake, chewing xylitol gum, and decreasing drinks with high amounts of sugar should also be emphasized
Finally a continuing care interval of about
3 months
is ideal to evaluate client’s whose oral health has deterriorated

As Regulated Health Professionals
It is our responsibility to identify clients who require modifications
We must enable safe and healthy provision of all clients.
Demonstrate empathy and knowledge of substance abuse
We must enable effective and successful dental hygiene care

Client Education
Substance Abuse
Schizophrenia
Signs & Symptoms
Dental Hygiene Care
Dental Hygiene Care
Physical Characteristics
Personal Characteristics
- like attention
- call for affection, which provides them a sense of security
- be cheerful and rarely irritable
- easily amused and tend to imitate
- occasional periods of stubbornness

(Wilkins, 2009)
Oral Manifestations
- lips to be dry, thickened and fissured
- macroglossia, deeply fissured & protruded tongue
- narrow jaw
- narrow palate
- Hyperplasia of the adenoids and the tonsils
- inflammed gingiva

*Mouth breather
* May present with gag
reflex
Oral
Manifestations
Tooth Anomalies:
Microdontia & Congenitally Missing Teeth
Delayed tooth eruption
Irregularities in tooth formation
Fused teeth
Peg laterals
Malocclusion
Attrition
Developmental Defects
Periodontal Disease
Dental Hygiene Process of Care
Medical Concerns
Congenital Heart Lesions
Obstructive Airway Problems
Susceptibility to Infections
Language, Visual and Hearing Impairments
Dental Hygiene Process of Care
Treatment Considerations
Pay close attention to medical history
Assess the behaviour
Booking appointments
Communication
Visual/Hearing Impairments
Implementation
Quick
Limited access in the mouth
Avoid using ultrasonic and air polisher
Chlorhexidine Rinse
Educating on Prevention
Oral Self Care very important
Ways to educate:
Tell, Show and Do
Simple Language
Frequent Repetition
Positive Reinforcement
Darby, 2012
Other Preventative Methods
o Sealants
o Chlorhexidine rinses
o Mouth rinses at home
o Nutritional Counseling- Alternatives for snacks and foods that are less cariogenic and acidic

Darby, 2012
Sensory Impairments
The
Homebound Client
What is a Homebound Client
The homebound client is an individual that does not have the capacity physically or mentally to retrieve oral health services within a designated dental practice setting. This type of client is an individual that experiences limitations in one or more activities of daily living and requires the need of home-based healthcare services.
Various Types of Homebound Clients
Homebound clientele extends from a variety of age groups with a common similarity of limited accessibility being confined within establishments such as hospitals, hospices, institutions, nursing homes, skilled nursing facilities, or private homes (Wilkins, 2013). Due to their individual functional dependence specials adaptations to the utilization of dental hygiene care and services are required.
Oral Health
Common Problems
• Periodontal infections
• Lack of daily personal oral care- inadequate bioflim removal
• Need for routine dental check-up
• Difficulty biting and chewing
• Losing weight/not eating because of oral problems
• Toothache/pain and abscess/swelling
• Trauma/fractured teeth
• Loose teeth
• Oral infections lost filings/crowns
• Dental caries
• Loose uncomfortable, or lost dentures

(Wilkins, 2013)
http://www.dentalhealth.org/blog/blogdetails/69
http://www.dentalhealth.org/blog/blogdetails/69
.VS.
Barriers to Care
Access
Clinicians
Dependence
Finances
Moving past the barriers
• Provide intra-oral/ extra-oral screening to triage clients who need treatment by a dentist
• Assist in preventing further complication of the client’s health status by identifying oral infections and other problems
• Provide routine screening to detect lesions that may be pathological, particularly those that may be early cancer
• Provide dental treatment and education interventions to prevent dental caries and periodontal infections that require extensive treatment
• Encourage adequate daily personal oral care, whether performed by a the client or a caregiver
• Provide palliative care for the individual with a shortened life span
• Contribute to the client’s general well-being and quality of life

Wilkins 2013
Preparing and Specializing Care
Recommendations of client care Wilkins, 2013 suggests the following:
• Request the assistance of a caregiver to be present throughout the procedure and to help demonstrate methods of personal daily oral hygiene
• Prevent distractions, refraining client visitors during care
• Move through the procedure at a slow pace ensuring the client is aware of what’s happening
• Listen attentively
• Be prepared to schedule multiple appointments to complete treatment despite inconvenience
• Prevent exhausting the client
• Observe on-going oral changes
• Provide client encouragement of biofilm control procedures

Equipment
Depending on the clients health conditions the hygienist may have to make accommodations to assist the procedure of treatment
Different Types of Homebound Clients
& Modifications to Dental Hygiene Care
Bed
Terminally Ill
Edentulous
Wheelchair
Unconcious
Key Points
Treatment of a client with mental illness
Clients State/capability
Condition
Signs and Symptoms
Mental health physician info
Consent
Care givers
medications & Side Effects
Diet
Alcohol or drug dependancy

What is Sensory Impairment
Incorporates hearing loss and visual loss (including partial sight and blindness)


Deficits of Hearing
The following modes of communication are used by hearing impaired clients:

Lip-reading or speech reading
American Sign Language (ASL)
Fingerspelling (American manual alphabet)
Writing
The use of an interpreter to translate spoken words into sign language
Electric devices

Basic ideas
to keep in mind when communicating with the client:
Ask if a lip reader or an interpreter is required.
Always face the client when speaking with him or her. Do not turn your back to them to retrieve a chart while conversing with the client.
Make sure the room is well lit.
Do not stand in front of bright light or window
Consider using a clear face shield instead of a mask,
Use diagrams and other visual aids whenever possible.
Review the College of Dental Hygienist of Ontario Guideline for providing accessible customer service.
Consider learning sign language.
Now there are clients who use a hearing aid and we need to make sure that all external noise is removed from the treatment room that includes:
Music
Saliva ejector and suction
Ultrasonic scalers and handpieces

Oral Self Care
Oral Clinical Findings
Due to the visual impairment these clients may be at a greater risk of poor oral hygiene as well as gingivitis and periodontitis.
This can occur by not being able to see their oral hygiene efforts and possibly from not being properly instructed on effective oral hygiene instructions. (Darby and Walsh, 2010)

Special considerations for Dental Hygiene Care
Verbal descriptions
Greeting the Client
describe yourself
Client should recognize the voices in the office
all obstacles need to be removed from the treatment area
Operatory Room setup
If the client has a guide dog do not pet the dog!

Special considerations for Dental Hygiene Care
Make sure to describe in detail each step of treatment including instruments and materials
Allow the client to handle the instrument
Prepare the client for the use of ultrasonic scalers and avoid unexpected application of compressed air and power driven instruments
Always inform the client when leaving and re-entering the room

Oral Self-Care Instructions
GAME TIME
Reference List
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Adapted from “Intech Open Sciences” Retrieved March 5, 2014, from http://www.intechopen.com/books/prenatal-diagnosis-and-screening-for-down-syndrome/oral-health-in-individuals-with-down-syndrome copyright © 2014 by InTech.

Adapted from “Intech Open Sciences” Retrieved March 5, 2014, from: http://www.intechopen.com/books/prenatal-diagnosis-and-screening-for-down-syndrome/oral-health-in-individuals-with-down-syndrome copyright © 2014 by InTech.

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Saunders/Elsevier Inc.

Darby, M., & Walsh, M. (2010, 3rd Edition). Dental Hygiene: Theory and Practice. San Francisco, CA: Saunders Elsevier

David B. Clark, BSc, DDS, MSc, FRCDC., (2008). Dental Care for the patient with schizophrenia. Canadian Journal of Dental Hygiene (CJDH) Vol. 42 (no 1), p.17-24.

David B. Clark, BSc, DDS, MSc, FRCDC., (2009). How understanding Psychiatric illness can help clinicians provide optimal oral health care. Canadian Journal of Dental Hygiene (CJDH) Vol. 43 (no 3), p.101-106.

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Reference List
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Janal, M. N., Keller, S., Khocht, A., & Schleifer, S. J., (2009). Dental care and oral disease in alcohol-dependent persons. Journal Of Substance Abuse Treatment, 37(2), 214-218. Elsevier: Philadelphia,PA.

Lypka, M., and Urata, M., (2007) Cocaine-Induced Palatal Perforation. New England Journal of Medicine 357:1956. University of California: Los Angeles, CA

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Rosmus Lori, RDH, BSc., Sandra J. Cobban, RDH, MDE. (2007). Bipolar Affective Disorder and the Dental Hygienist. Canadian Journal of Dental Hygiene (CJDH), Vol. 41 (no 3), p.72-84.
Ruler tapped to toothbrush to extend the handle, Adapted from “Westchester Institute of Human Development.” Retrieved on March 7 2014 from http://www.wihd.org/page.aspx?pid=671#.UxpINVcqgqA Copyright © 2002-2013 Westchester Institute for Human Development

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Surround® Toothbrush, Compact head toothbrush, Adapted from “Specialized Care Co, Inc.” Retrieved on March 7 2014 from http://www.specializedcare.com/shop/pc/Surround-Toothbrushes-c37.htm Copyright © by 1999-2009 by Specialized Care Co.

Tennis ball attached to end of the toothbrush, Adapted from “Westchester Institute of Human Development.” Retrieved on March 7 2014 from http://www.wihd.org/page.aspx?pid=671#.UxpINVcqgqA Copyright © 2002-2013 Westchester Institute for Human Development

Wide elastic band to hold the toothbrush in hand, Adapted from “Westchester Institute of Human Development.” Retrieved on March 7 2014 from http://www.wihd.org/page.aspx?pid=671#.UxpINVcqgqA Copyright © 2002-2013

Wilkin, E. M. (2013). Clinical practice of the dental hygienist (11th ed.). Philadelphia, PA: Lippincott Williams & Wilkins/Wolters Kluwer.

Reference List
Wilkins, E. M. (2009). Clinical practice of the dental hygienist (10th ed.). Philadelphia, PA:
Lippincott Williams & Wilkins/Wolters Kluwer.

Wilkins, E.M. (2013). HYPERLINK "http://www.lww.com/webapp/wcs/stores/servlet/product_Clinical-Practice-of-the-Dental-Hygienist_11851_-1_9012052_Prod-9781608317189" Clinical Practice of the Dental Hygienist (11 th ed.).Philadelphia, Pennsylvania: Lippincott, Williams & Wilkins.

Wilkins, E.M. (2013). Clinical Practice of the Dental Hygienist (11th ed.).Philadelphia, Pennsylvania: Lippincott, Williams & Wilkins.

Periodontal Disease in Down Syndrome Clients
http://www.intechopen.com/books/prenatal-diagnosis-and-screening-for-down-syndrome/oral-health-in-individuals-with-down-syndrome
http://www.intechopen.com/books/prenatal-diagnosis-and-screening-for-down-syndrome/oral-health-in-individuals-with-down-syndrome
https://www.ahchealthenews.com/2014/02/04/special-needs-patients-receive-specialdental-care
Locations
http://norwich.tab.co.uk/2012/12/05/my-experience-schizophrenia/
http://psychedelic-information-theory.com/Erratic-Hallucination
http://physiologizing.blogspot.ca/2013/03/schizophrenia-in-dish.html
http://www.choosehelp.com/news/addiction-treatment/common-antipsychotic-medication-aripiprazole-might-double-as-effective-cocaine-addiction-medication
http://anaidadentalhygieneblog.wordpress.com/
http://www.merionvillagedental.com/index.cfm/PageID/8516
Wilkins, (2013)
https://www.ucsf.edu/blog/2014/01/ucsf-group-hosts-presentation-health-care-challenges-people-disabilities
http://www.osisa.org/law/zambia/dealing-disability
http://www.km-rentals.com/mobility-equipment-orlando
http://www.smartplanet.com/blog/smart-takes/darpa-aims-to-control-prosthetic-limbs-with-brain-implants/4890
http://www.chaneco.co.uk/orthotic-product.asp?prodId=399&specialoffer=true&view=all&s=Universal%20Leg%20Brace%20-%20Reduced!
Sensorineural hearing loss damage to the nerve pathways from the inner ear to the brain or to the inner ear itself.
It decreases the ability to hear faint sounds
Caused by many factors such as: birth trauma, prenatal infection in the mother, malformation of the inner ear, drugs that are toxic to the auditory system (aspirin), illnesses, aging and exposure to loud noise.
Sensorineural hearing loss cannot be medically or surgically corrected.

(Darby and Walsh, 2010)
http://www.phonak.com/com/b2c/en/hearing.html

Demonstrate step by step correct brushing and flossing techniques while the client watches every detail in the mirror
Use visual aids and disclosing solution to identify plaque biofilm
Always provide the client with written instructions on causes of gum disease, brushing and flossing and preventive measures against gingivitis and periodontitis that can be reviewed at home
http://www.mlive.com/health/index.ssf/2011/05/improving_muskegons_health_lit.html
Should be given clearly and concisely
Demonstrate proper brushing technique
Clients can be taught to feel their teeth with their tongue to verify if they have been thoroughly cleaned
When flossing they should be able to hear a squeak when the tooth surface is clean
Audiotapes or materials should be prepared on braille
Is important to know that when instructing a client with glaucoma you make sure to sit directly in front of them because the loss of peripheral vision. You also need to avoid tilting back a client because this causes increase pressure and pain to their eyes

http://www.ehow.com/how_2095658_read-basic-braille-phrases.html

Vision loss can occur in many different ways, for instance the client can be slightly affected or have complete blindness without perception of light.
It can affect the eye via the optic nerve to the visual region of the cerebral cortex
 According to Wilkins (2013), the leading causes of blindness are:
- Macular degeneration- an eye disease that affects central vision
- Glaucoma – includes damage to the optic nerve caused by high pressure inside the eye
- Diabetic retinopathy – a complication caused by diabetes
- Cataracts – is a cloudy lens that blocks light from reaching the retina causing the vision to be blurred or hazy.

Visual Impairment
http://www.healthcareasia.org/2012/indonesia-to-face-higher-prevalence-of-blindness-sight-disorders-official/

http://www.km-rentals.com/mobility-equipment-orlando
(Darby and Walsh, 2010)
(Darby and Walsh, 2010)
(Darby & Walsh, 2010)
(Wilkins, 2013)
http://www.carewatchharingey.co.uk/support-for-physical-disabilities/
(Wilkins, 2013)
(Wilkins, 2013)
http://www.wihd.org/page.aspx?pid=671
http://www.wihd.org/page.aspx?pid=671
http://www.wihd.org/page.aspx?pid=671
http://www.wihd.org/page.aspx?pid=671
http://www.specializedcare.com/shop/pc/Surround-Toothbrushes-c37.htm
http://www.oralb.com/products/deepsweep-5000-wireless-smartguide-plus-electric-toothbrush/
http://freshome.com/2011/01/21/friendly-dental-office-with-baroque-design-influences-in-bucharest/
http://deltadentalazblog.com/what-is-a-dental-hygienist-and-why-are-they-important/
http://www.smilesbystaci.net/aboutus.html
http://www.turnto23.com/lifestyle/dental-care-being-provided-at-home-for-frail-seniors01032013
http://www.taipeitimes.com/News/front/archives/2012/10/25/2003546027
http://pridedentaloffice.com/category/oral-hygiene/
http://www.visitingdentalmobilehomecarenj.com/dental-services/
http://fremonttribune.com/news/local/midland-students-earn-cna-certificates/article_17b5a1d8-7ee0-11df-a7fc-001cc4c002e0.html
http://www.ericasmobilesmiles.ca
http://www.adha.org/ce-course-11
Full transcript